Method of spinal fixation using adhesive media

ABSTRACT

Disclosed are methods of spinal fixation involving application of a liquid medium which cures, hardens, polymerizes or otherwise serves to bind adjacent vertebrae together. The fixation which results from this binding may be temporary or essentially permanent in duration, and may be used to treat conditions or disease of the spine, such as inflammation, instability or fracture. In a preferred embodiment, the liquid medium comprises a low viscosity cyanoacrylate-based adhesive.

RELATED APPLICATION INFORMATION

This application is a Continuation of U.S. application Ser. No.10/827,101 filed on Apr. 19, 2004, now U.S. Pat. No. ______, which is aContinuation of U.S. application Ser. No. 10/041,652 filed Dec. 28,2001, now U.S. Pat. No. 6,723,095, both the disclosures of which areincorporated by reference in their entirety.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to a method of spinal fixation involvingapplication of a liquid medium which cures, hardens, polymerizes orotherwise serves to bind adjacent vertebrae together. The fixation whichresults from this binding may be temporary or essentially permanent induration.

2. Description of the Related Art

The spinal vertebrae are separated by cartilage disks, filled with agelatinous substance, that provide cushioning to the spinal column.These disks may herniate or rupture from trauma or strain, especially ifdegenerative changes have occurred in the disk.

A herniated intervertebral disk, also known as a slipped or ruptureddisk, is a condition in which part or all of the soft, gelatinousnucleus pulposus in the central portion of an intervertebral disk isforced through a weakened part of the annulus fibrosis, resulting inback pain and nerve root irritation.

Most herniation takes place in the lumbar area of the spine. Lumbar diskherniation occurs 15 times more often than cervical disk herniation, andit is one of the most common causes of lower back pain. The cervicaldisks are affected 8% of the time and the thoracic disks only 1 to 2% ofthe time. When lumbar disk herniation occurs, nerve roots, the largenerves that branch out from the spinal cord, may become compressedresulting in neurological symptoms such as pain or weakness in the backand lower extremities.

Although minor cases of disk herniation may be treated with bed rest andmedications to relieve pain and reduce inflammation, surgery may beindicated for people who fail to respond to bed rest and medications.

One common type of surgery performed to alleviate back pain isdiscectomy. Discectomy involves the surgical removal of the diseaseddisc, thereby relieving the pressure. In spite of the fact that theprocedure has been done for many years, few studies have been conductedto determine its real effectiveness. Scar tissue may develop afterdiscectomy, which, in some cases, can cause continued pain.

Another common procedure is spinal fusion. Spinal fusion involves makinga percutaneous incision or puncture over the affected area of the spineand joining the vertebrae together using bone grafts and/or rods made ofmetal or other materials of substantial strength.

Another procedure performed is laminectomy. Laminectomy is performed toremove the protruding disk. This procedure involves removing the bonethat curves around and covers the spinal cord (lamina) and the tissuethat is causing pressure on the nerve or spinal cord.

Complications of spinal surgery can include nerve and muscle damage,infection, scarring, and the need for re-operation. Patients oftenremain hospitalized for several days after surgery, and in bed foranywhere from a few days to a few weeks following surgery. A back braceor cast may be necessary for weeks following the surgery to immobilizethe spine until the fusion has occurred.

SUMMARY OF THE INVENTION

In accordance with one preferred embodiment, there is provided a methodof temporary spinal fixation. The method comprises identifying a firstand a second adjacent surfaces in a spine, the first and second surfacesin sliding contact with each other at a joint and introducing a mediumbetween the first and second surfaces which undergoes a physical orchemical change to immobilize the joint.

In accordance with another preferred embodiment, there is provided amethod of immobilizing a portion of the spine. The method comprisesidentifying a joint between a first vertebra and a second vertebra whichis to be immobilized, and administering an adhesive medium to bond atleast a first superior articular process on the first vertebra to acorresponding first inferior articular process on the second vertebra,wherein the medium comprises cyanoacrylate.

In accordance with another preferred embodiment, there is provided amethod of treating inflammation in the spine. The method comprisesidentifying a joint between a first vertebra and a second vertebra whichis in the vicinity of an inflammation, and administering an adhesivemedium to bond at least a first superior articular process on the firstvertebra to a corresponding first inferior articular process on thesecond vertebra to temporarily immobilize the joint for a sufficienttime to treat the inflammation, wherein the administering step isaccomplished without a surgical cut down.

In accordance with still another preferred embodiment, there is provideda method of immobilizing a portion of the spine. The method comprisesidentifying a joint between a first vertebra and a second vertebra whichis to be immobilized, and administering a thin film of a mediumcomprising an adhesive within the joint to bond at least a firstsuperior articular process on the first vertebra to a correspondingfirst inferior articular process on the second vertebra.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a left lateral view of the lumbar region of the human spine.

FIG. 2 is a posterior view of the third and fourth lumbar vertebra ofthe human spine.

FIG. 3 is a superior view of an intervertebral disk.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

The present invention relates to a method of spinal fixation involvingapplication of a liquid medium which cures, hardens, polymerizes orotherwise serves to bind adjacent vertebrae together. The fixation whichresults from this binding may be temporary or essentially permanent induration, and may be used to treat inflammation, disk herniation, and/orfracture or instability in the spine.

The terms “medium” and “media” as used herein, refer to the liquidmaterial used according to preferred embodiments herein to join one ormore adjacent vertebrae. Preferred media comprise an adhesive, which isused in a broad sense to include single component or multiple componentmaterials, curable compositions, polymerizable compositions, cements, aswell as other types of materials or compounds, presently known orlater-developed, which may be used to join, bond or adhere surfaces ormaterials together. Suitable adhesives include both biological andnon-biological adhesives. The class of materials referred to herein asadhesives includes curable compositions, including, but not limited tothose which cure by mixing two or more component parts, those which cureby cross-linking, and those which cure in the presence of someactivator, accelerant or catalyst, including, but not limited to water,heat, chemicals, or radiation. Adhesives also include polymerizablecompositions, which preferably comprise one or more monomers oroligomers which polymerize or further polymerize following applicationto the desired site. A medium may consist solely of or essentially ofone or more adhesives, or it may further comprise one or more additionalmaterials. Additional materials include those which modify properties ofthe adhesive, as well as those which impart other desirable propertiesor characteristics to the medium.

Examples of preferred adhesives include cyanoacrylates, epoxies,fibrin-based adhesives, as well as other presently known orlater-developed materials suitable for use in the methods disclosedherein. Polymerizable adhesives that have been cross-linked orco-polymerized with other compounds that may alter elasticity, modifyviscosity, aid biodegradation or change some other property of theresulting material may be used in media. For example, polyacrylic acidmay be cross-linked to a cyanoacrylate to form compounds which may allowfor greater bioabsorbability.

Cyanoacrylates are among the preferred adhesives used in media asdisclosed herein. Among the reasons why cyanoacrylates are preferred arethat they can harden almost instantaneously on contact with surfaceshaving moisture thereon, including most tissues and surfaces in the bodyof an animal, such as a human. Preferred cyanoacrylates include, but arenot limited to, methyl cyanoacrylate, ethyl cyanoacrylate, n-propylcyanoacrylate, isopropyl cyanoacrylate, n-butyl cyanoacrylate, isobutylcyanoacrylate, n-amyl cyanoacrylate, isoamyl cyanoacrylate,3-acetoxypropyl cyanoacrylate, 2-methoxypropyl cyanoacrylate,3-chloropropyl cyanoacrylate, benzyl cyanoacrylate, phenylcyanoacrylate, alkenyl cyanoacrylate, butyl-2-cyanoacrylate, alkoxyalkyl2-cyanoacrylates, fluorinated 2-cyanoacrylates, and carbalkoxyalkylcyanoacrylates, depending upon acceptable toxicity and other propertiesfor a given application. More preferably the adhesive compound comprisesethyl cyanoacrylate or butyl-2-cyanoacrylate. These latter twocompounds, are available commercially from Loctite Corporation(Hartford, Conn.) or Pacer Technology (Rancho Cucamonga, Calif.). Othermembers of the cyanoacrylate family may be commercially available or maybe synthesized according to published procedures or analogous methods asis within the abilities of one skilled in the art. Also suitable arecommercially available cyanoacrylate based tissue adhesives such asDermabond® (Johnson & Johnson, New Brunswick, N.J.).

Preferred fibrin-based adhesives include those which include componentshaving human, animal or recombinant origin. Such adhesives include, butare not limited to, adhesives comprising thrombin and fibrinogendelivered separately or mixed at the site to be bonded, adhesivescomprising fibrinogen and Factor XIII, adhesives produced near the timeof use from autologous components, and adhesives as described in U.S.Pat. Nos. 6,019,993, 6,063,297, 5,716,645, 5,962,405, 5,605,887,5,883,078, and 5,464,471, the disclosures of which are incorporatedherein by reference in their entireties. Also suitable are commerciallyavailable fibrin based adhesives, including Tissucol® (Immuno A.G.,Vienna, AT) and Tisseel® (Baxter Healthcare Corp., Deerfield, Ill.).

Media employed in preferred embodiments may comprise components andmaterials in addition to adhesive. Such other components include, butare not limited to, inhibitors, activators, catalysts, colorants, dyes,including colored dyes, radioscopic dyes and fluoroscopic dyes,radiopaque components, drugs, viscosity modifiers, and wetting agents.In one preferred embodiment, a medium comprises a cyanoacrylate and alow viscosity inhibitor. One preferred low viscosity inhibitor is sulfurdioxide. Such embodiments preferably have a very low, water-likeviscosity such that capillary action or the natural wetting action cancause the medium to be pulled in to a thin opening, including the spacebetween the articular processes which are coated with smooth, slipperycartilage or other such slidable areas to be fused.

In discussing the viscosity of the media in the context of the preferredembodiments, the viscosity referred to generally is the viscosity of themedium at the time it is being applied. Following application, themedium will increase in viscosity until it “sets up” to a final solid orrelatively solid state due to the action of one or more physical orchemical mechanisms in the medium, including, but not limited to curing,cross-linking, polymerizing, hardening, and evaporation of solvent. Oncethe medium has set up, it preferably takes a solid form, which may besomewhat flexible or may be relatively stiff. In one embodiment, thepre-application or application time viscosity of a medium is preferablyabout 10-50,000 centipoise (cp), more preferably about 10-5,000 cp or10-100 cp, including about 20 cp, about 30 cp, about 50 cp, and about 75cp. Media having viscosities outside of these stated ranges and valuesmay also be suitable, depending upon one or more of several factors,including, but not limited to the location and method of application. Ina preferred embodiment, the medium has a viscosity sufficiently low topermit it to be pulled into a small gap between surfaces under capillaryaction.

It is preferred that media used in the methods described herein exhibita good ability to coat or wet the surfaces of the spine to which theyare applied so as to aid application and creation of a firm and evenbond.

Another characteristic of a medium is the time required for the mediumto set up to the point where a reasonable degree of fixation orimmobilization of the target region of the spine is achieved. Areasonable degree of fixation is generally thought to be achieved whenat least moderate movement of the back area of the patient does notdisrupt the bond. Once it has set up, a medium may still undergo furtherpolymerization, reaction, curing, hardening or other chemical orphysical phenomenon to achieve a final state or bond. It is preferredthat the set up time is fairly short, so as to shorten the overall timeof the procedure. A short set up time also allows the physician (orother such practitioner) to confirm that the fusion or immobilizationhas occurred properly. It is also preferred, however, that the set uptime not be too short as to interfere with the physician's need toadjust or position the vertebrae and/or other surfaces being joinedduring the procedure. In one embodiment, the set up time is preferablyless than about 20 minutes, less than about 10 minutes, or less thanabout 5 minutes, including about 10 seconds to about 10 minutes, andabout 30 seconds to about 2 minutes. Media having set up times outsideof these stated ranges and values may also be suitable, depending uponone or more of several factors, including, but not limited to the methodof application and the time needed to properly position the spine.

The set up time can be altered by choice of adhesive in the medium.Additionally, for a given adhesive, the set up time can be increased ordecreased by the use of (or by varying the amounts of) catalysts,activators, inhibitors, monomers, and other such components in themedium.

Depending upon the length of time it is desired for the vertebrae to befixed together, the degree of biodegradability or bioabsorbability inthe medium employed may be varied. For example, if temporary fixation isdesired, such as for a period of weeks or months, a higher degree ofbiodegradability or bioabsorbability in the medium is desired. Temporaryfixation can be for a period of about 1 to 12 months, or 1 to 5 weeks,although longer and shorter periods of time are also contemplated. If,however, more permanent fixation is desired, such as for a period ofseveral years, it is preferable to use a medium that is only slowlydegradable or substantially nonbiodegradable. Permanent orsemi-permanent fixation can be for a period of about 1 to 10 years,although longer or shorter periods of time are also contemplated. Modesof degradation or dissipation of the medium in the body over timefollowing fixation include, but are not limited to, those which occurdue to the presence of heat, water or aqueous fluids, enzymes or otheractive compounds, physical stress and/or shear forces. Degradation ordissipation may also result from a combination of modes.

There is a wide variation in the rates and facility of in vivobiodegradation of polymers made from monomers which may be used in mediaaccording to preferred embodiments. Generally, cyanoacrylates and otheradhesives that have substituents that are small and/or contain one ormore oxygen-containing functional groups (e.g. ether, ester, carbonyl)appear to have increased biodegradability rates. Conversely,cyanoacrylates and other adhesives having long chain alkyl groupslacking in oxygen-containing or polar functional groups as substituentsmay tend to form polymers that biodegrade more slowly. There are alsoindications that the biodegradation rate of polymer-based adhesives isaffected by the polymer molecular weight and crystallinity of thepolymer, with higher molecular weight and higher crystallinity generallyindicating a more stable, less degradable material.

To effectively immobilize or reduce the mobility of the targeted regionof the spine, a medium is applied to abutting or adjacent surfaces in atleast two adjacent vertebrae. Such surfaces preferably move with respectto each other by sliding, rocking, or other such movement which occursin a normally functioning spine. In accordance with one embodiment, atleast one medium is applied to one or more adjacent surfaces, followedby bringing the surfaces together. In a preferred embodiment, at leastone medium is applied to form a film or layer or to fill a space betweenthe surfaces. Following application, the film or layer preferably coversthe entirety of the surfaces so as to have a larger, but preferablystill thin, bonding surface and achieve a stronger bond. Similarly, ifthe application of medium entails filling a space, it is preferred thatsubstantially the entire space be filled so as to maximize bondingforce. Following the application of media and any time needed for setup, curing, or other physical and/or chemical changes, the surfacesand/or the vertebrae to which they are attached should be substantiallyprevented from moving relative to each other.

In a preferred embodiment, the introduction or application of medium toa site is effected using a tubular introducer, including, but notlimited to a cannula, needle or other hollow structure. The term“tubular” is intended to convey that preferred introducers are elongate,hollow structures which allow for the passage of media through thehollow space, rather than to convey any particular shape or profile.Accordingly, an introducer may have any suitable cross-sectional shapeincluding circular, ovoid, ellipsoid, polygonal, etc. In one embodiment,a first end of the introducer is attached to a reservoir or containerwhich provides for storage of medium before and/or during application. Asecond end of the introducer is preferably shaped into or fitted with arelatively fine tip to aid in precise application of media. In anespecially preferred embodiment, the second end of the introducer is aneedle-type point which also can readily puncture the skin to aid inpercutaneous application of the medium.

Media is expressed through the introducer using any suitable means,including, for example, pressure, gravity, and capillary action. One endof the introducer is placed at the desired location and the medium isthen applied or expressed in the desired quantity. The medium may beexpressed directly into a target joint or capsule or onto one or moresurfaces. For example, the tip of the introducer may be placed near thecenter of a joint and the medium expressed. Alternatively, the tip ofthe introducer may be placed within a capsule or other space and themedium expressed to substantially fill, or at least partially fill, thespace. The medium may also be expressed near the edge of a joint, spaceor surface and then be forced by the flow of material into the joint,space or surface. If a low viscosity medium is used, the medium may beexpressed near the edge of a joint, space, or surface or it may beplaced in contact with same, allowing the medium to be drawn into thejoint, space or surface by means of capillary action.

In a preferred embodiment, two or more vertebrae are fused together.Referring to FIG. 1 the lumbar region of the spine, containing fivevertebrae (L1-L5), is illustrated in a left lateral view. A posteriorview of the third and fourth lumbar vertebrae (L3-L4) is illustrated inFIG. 2. Both FIGS. 1 and 2 are dissections which show primarily only thebony portions and the intervertebral disks. Although the lumbar spine isshown, the techniques and methods disclosed herein may be used in oradapted to other locations in the spine. Furthermore, these techniquesmay be used and adapted for use in repair of bones and/or cartilage inother parts of the body.

Each vertebra comprises a generally cylindrical vertebral body 10 whichis separated from its adjacent vertebrae by intervertebral disks 12.Each vertebra further comprises several processes, among them thesuperior and inferior articular processes. The two superior articularprocesses 14 of each vertebra project upward and the two inferiorarticular processes 16 of each vertebra project downward. The superiorarticular processes 14 are wider apart than the inferior articularprocesses 16, since, when placed together in the spinal column, theinferior articular processes 16 of one vertebra are embraced by thesuperior processes 14 of the subjacent vertebra. Each superior process14 terminates in a facet 18 which is concave and looks backward andmedialward. Each inferior process 16 terminates in a facet 20 which isconvex and directed forward and lateralward. The facets 18 of thesuperior processes 14 of one vertebra thus mate with the facets 20 ofthe inferior processes 16 of the vertebra directly above to form azygapophyseal joint 22 where each pair of corresponding articularprocesses meet. Although not shown in the figures, there is a ligamentwhich extends from the inferior process of one vertebra to the superiorprocess of the vertebra immediately below, encapsulating thezygapophyseal joint 22 in what is known as the capsule of thezygapophyseal joint.

In accordance with one preferred embodiment, a medium is applied to oneor both zygapophyseal joints between a pair of vertebrae. Theapplication may occur within the joint, or the medium may be appliedprimarily to a facet of a superior process of one vertebra and/or to thecorresponding facet of the inferior process of the superjacent vertebra.It is preferred that enough media be applied to at least form a film orlayer over the entire surface area of a joint or facet, although smalleror larger amounts of medium may be used.

In an alternate embodiment, the medium is placed into the capsule of thezygapophyseal joint to substantially fill, or at least partially fillthe capsule with medium. In this manner, the capsule may be used both asa means of containing the medium and also as a way of extending thesurface area over which the fusing bond acts.

As noted above, the fixation or bonding involving the articularprocesses between two vertebrae may be either unilateral (one pair ofarticular processes) or bilateral (both pairs of articular processes).Furthermore, this process can be repeated to provide for the fixation ofmore than one pair of vertebrae in a single spine. The multiple fixationpoints may be in adjacent groups of vertebrae, or they may benon-contiguous. In preferred embodiments, the vertebrae which are fixedtogether are in the lumbar region of the spine, and may also includefixation to the first vertebra of the adjacent sacral region. In oneembodiment, all five vertebrae which constitute the lumbar region arefixed together.

The fixation methods described above which involve the articularprocesses may be performed alone, or it may be combined with othertechniques of fusing or fixing the spine. For example, a medium may beused to fix the articulate processes in combination with use of rods orwires to fix the vertebral bodies. Alternatively, use of a medium to fixthe articulate processes may be combined with methods which involvestimulating the growth of a bony mass or fusion body to fix the spine.The fixation provided by the medium can provide extra support andstability to the spine so as to increase the chances of havingsuccessful fusion provided by the growth of bone.

Fixation of the spine need not be confined to the articular processes.Other adjacent portions of adjoining vertebrae may be fixed using amedium. For example, a medium could be applied to fix adjacent vertebralbodies. One such method could involve applying a medium to the adjacentvertebral bodies and/or the intervertebral disk (or artificial diskreplacement) which separates them. Alternatively, a medium could beapplied to adjacent vertebral bodies to stabilize them followingdiscectomy.

Although many statements herein refer to preferred embodiments in whichone medium is applied, it is presently contemplated that more than onemedium may be applied, either in concert or in series.

The temporary or more permanent fixation that results from applicationof preferred methods disclosed herein may be used to treat conditionsincluding, but not limited to, inflammation, disk herniation,instability, and fracture. The immobilization which results fromfixation can provide an environment in which spinal inflammation isreduced and in which a disk may heal itself, either entirely or enoughto reduce or eliminate the symptoms of disk herniation. The fixation canprovide stabilization of a region in the spine to allow forstrengthening of the muscles and other tissues in the spine throughphysical therapy, growth of a stable fusion body, and the like toprovide longer term repair and relief. Even if a procedure must berepeated periodically, preferred procedures, especially percutaneousprocedures, are less invasive and less traumatic than conventionalsurgical procedures. Similarly, procedures described herein may also beused as a “bridge” to a more extensive surgical procedure, providing foran alleviation of symptoms, lessening of pain, provision of stability tothe spine and/or other such aid to the patient on a temporary basisuntil such surgical procedure can be performed.

In some embodiments, application of a medium to one or more locations isdone in a surgical procedure. The surgical procedure may involve onlythe fixation by means of medium, or it may be done in combination withother procedures, including, but not limited to discectomy, fusion, andlaminectomy. Such other surgical techniques involving the spine may beenhanced or improved by incorporation of techniques involving fixationusing a medium as described herein.

Alternatively, fixation using a medium may be performed percutaneously,without surgical cut-down, whether performed alone or in combinationwith some other technique or procedure, including, but not limited to,discectomy and application of a medicament. In one preferred embodiment,fixation is performed percutaneously with the spine and introducer beingmonitored and guided using fluoroscopy. Use of fluoroscopy to visualizethe spine and deliver drugs or perform a spinal puncture is known andwidely used. These same techniques can be adapted to visualize and guidethe introducer to the desired location, be it a joint, capsule, surfaceor otherwise, to apply a medium. In a procedure using fluoroscopy, it ispreferred that the medium contains a fluoroscopic dye or other agent toenable the medium to be visualized during the procedure, which allowsthe physician to monitor both the amount of medium delivered and thelocation of delivery. Techniques other than fluoroscopy which allowvisualization of the spine and introducer including, but not limited to,ultrasound, may also be used in connection with preferred percutaneousprocedures.

Both surgical and percutaneous methods may further include a step ofaligning the spine prior to introducing the medium to help ensure thatthe vertebrae will have proper positioning and alignment when fixed.Preferred methods may include the additional step of providing ananesthetic, such as an epidural anesthetic, prior to initiating theintroduction of medium or other aspects of a procedure.

One preferred embodiment involves a method of temporary spinal fixation.The method comprises identifying first and second adjacent surfaces inthe spine that are in contact with each other at a joint, andintroducing a medium between the first and second surfaces (which mayinclude one or both such surfaces) or into the joint. The mediumpreferably then undergoes a physical or chemical change to fix orimmobilize the joint. For such temporary fixation, it is preferred thatmedia used are susceptible to biodegradation or bioabsorption.

In accordance with another preferred embodiment, there is a method ofimmobilizing a portion of the spine. The method comprises identifying ajoint between two vertebrae which is to be immobilized, andadministering an medium to bond at least one surface on a first vertebraand an adjacent surface on the second vertebra, preferably a firstsuperior articular process on one vertebra and the correspondinginferior articular process on the second vertebra.

In another preferred embodiment, there is provided a method of treatinginflammation in the spine. The method comprises identifying a jointbetween a first vertebra and a second vertebra that is in the vicinityof an inflammation, and administering a medium to bond at least onesurface, preferably a first superior articular process, on the firstvertebra to an adjacent second surface, preferably the correspondingfirst inferior articular process, on the second vertebra to temporarilyimmobilize the joint for a sufficient time to treat the inflammation,wherein the administering step is preferably accomplished without asurgical cut down.

The procedures described herein may be coupled with epiduraladministration of one or more anti-inflammatory agents, including, butnot limited to, cortisone and other steroidal compounds. In preferredembodiments, the administration of the medium and/or theanti-inflammatory agent is performed using fluoroscopy to aid inplacement at the desired site.

Media may also be used to repair or augment the intervertebral disks. Asshown in FIG. 3, a disk 12 comprises two main regions: the annulusfibrosis 24 and the nucleus pulposus 26. The nucleus pulposus 26comprises a relatively soft gelatinous material that acts as a “shockabsorber” in the spine. It is surrounded and protected by the annulusfibrosis 24, a ring of relatively tough tissue. Herniation occurs whensome, or even substantially all, of the nucleus pulposus is forcedthrough a split, rupture, or weakened area of the annulus fibrosis.

Although, as noted above, it is believed that small ruptures in a diskcan heal if the spine is rested or immobilized in the region of theinjured disk, larger ruptures in which there has been an expulsion oflarger amounts of pulpous material are not currently believed to becapable of self-repair. If the enucleated material is of a sufficientquantity to result in a change in the shape or size of the disk,instability of the spine may result. In such circumstances, it may bedesirable to add medium to the disk to augment any remaining nucleuspulposus. Preferably the medium used in such augmentation has elastic orresilient properties to mimic the natural contents of the nucleuspulposus. Adhesive properties of the medium can help the medium stay inplace inside the annulus fibrosis. Preferably the medium is expressedinto the interior of the disk using a tubular introducer. This proceduremay be performed percutaneously or surgically, and may be done incombination with removal of enucleated pulpous material and/or with anyof the aforementioned fixation techniques.

In addition to augmenting the nucleus, application of a medium may beused repair the tear, hole, or other such disruption in the annulusfibrosis through which enucleation occurred. Such medium may be of asimilar or different composition as the medium used to augment thenucleus pulposus. Alternatively, in those cases where sufficient naturalpulpous material remains in the disk, a medium may be used to repairtears, holes, and other disruptions in the annulus fibrosis with minimalor no augmentation of the nucleus. In such situations, the adhesiveproperties of the medium allow for repair or sealing of the damagedannulus when it is applied to one or more surfaces thereof.

The various methods and techniques described above provide a number ofways to provide fixation or immobilization of at least a portion of thespine. Of course, it is to be understood that not necessarily allobjectives or advantages described may be achieved in accordance withany particular embodiment described herein. Thus, for example, thoseskilled in the art will recognize that the methods may be performed in amanner that achieves or optimizes one advantage or group of advantagesas taught herein without necessarily achieving other objectives oradvantages as may be taught or suggested herein.

Furthermore, the skilled artisan will recognize the interchangeabilityof various features from different embodiments. Similarly, the variousfeatures and steps discussed above, as well as other known equivalentsfor each such feature or step, can be mixed and matched by one ofordinary skill in this art to perform methods in accordance withprinciples described herein.

Although the invention has been disclosed in the context of certainembodiments and examples, it will be understood by those skilled in theart that the invention extends beyond the specifically disclosedembodiments to other alternative embodiments and/or uses and obviousmodifications and equivalents thereof. Accordingly, the invention is notintended to be limited by the specific disclosures of preferredembodiments herein, but instead by reference to claims attached hereto.

1. A method of treating a spine, comprising: accessing a joint capsulearound a first facet on a superior articular process of a first vertebraand a second facet on a corresponding inferior articular process of asecond vertebra; introducing a medium into the joint capsule to securethe orientation between the first vertebra and second vertebra; and.adjusting the position of the first vertebra and second vertebra.
 2. Themethod of treating the spine as in claim 1, wherein the adjusting occursprior to introducing the medium.
 3. The method of treating the spine asin claim 1, wherein the adjusting occurs after introducing the medium.4. The method of treating the spine as in claim 1, wherein the adjustingoccurs while introducing the medium.
 5. The method of treating the spineas in claim 1, wherein introducing a medium occurs partially bycapillary action into the joint capsule.
 6. The method of treating thespine as in claim 1, wherein introducing a medium occurs partially bypressure into the joint capsule.
 7. The method of treating the spine asin claim 1, wherein introducing a medium occurs partially by gravityinto the joint capsule
 8. A method of treating a spine, comprising:inserting a hollow introducer into a first joint capsule between twovertebra; introducing a medium into the first joint capsule; aligningthe two vertebra; and securing the orientation between the two vertebra.9. The method of treating the spine as in claim 8, wherein the aligningoccurs prior to introducing the medium.
 10. The method of treating thespine as in claim 8, wherein the aligning occurs during the introductionof the medium.
 11. The method of treating the spine as in claim 8,wherein the aligning occurs after introducing the medium.
 12. The methodof treating the spine as in claim 8, wherein securing the orientationbetween the two vertebra occurs less than about 20 minutes afterintroducing the medium.
 13. The method of treating the spine as in claim12, wherein securing the orientation between the two vertebra occursless than about 10 minutes after introducing the medium.
 14. The methodof treating the spine as in claim 13, wherein securing the orientationbetween the two vertebra occurs less than about 5 minutes afterintroducing the medium.
 15. The method of treating the spine as in claim12, wherein securing the orientation between the two vertebra occursbetween about 10 seconds to about 10 minutes.
 16. The method of treatingthe spine as in claim 14, wherein securing the orientation between thetwo vertebra occurs between about 30 seconds to about 3 minutes.
 17. Amethod of treating a spine, comprising percutaneously introducing amedium into a zygapophyseal joint capsule between two vertebra toimmobilize the two vertebra.
 18. The method of treating a spine as inclaim 17, wherein the medium is an adhesive.
 19. The method of treatinga spine as in claim 17, wherein the medium comprises a radio-opaquecomponent.
 20. The method of treating a spine as in claim 18, whereinthe adhesive is a cyanoacrylate.